New Medical Assistant
Advance to Patient Care and Needs

Reporting Although physicians determine the overall medical management of a patient requiring medical care and other healthcare services, they depend upon the assistance of other members of the healthcare team when implementing and evaluating that patient's ongoing treatment. Medical assistants often spend more time with patients than other healthcare or medical staff members. This places them in a key position as data collecting and reporting resource persons.

Chapter 10
Reporting and Charting Procedures

Although physicians determine the overall medical management of a patient requiring medical care and other healthcare services, they depend upon the assistance of other members of the healthcare team when implementing and evaluating that patient's ongoing treatment. Medical assistants often spend more time with patients than all other providers. This situation places them in a key position as data- collecting and -reporting resource persons.

The systematic gathering of information is called data collection and is an essential aspect in assessing an individual's health status, identifying existing problems, and developing a combined plan of action to assist the patient in his health needs. The initial assessment is usually accomplished by establishing a health history. Included in this history are elements such as previous and current health problems; patterns of daily living activities, medication, and dietary requirements; and other relevant occupational, social, and psychological data. Additionally, both subjective and objective observations are included in the initial assessment gathering interview and throughout the course of hospitalization.

REPORTING
Accurate and intelligent assessments are the basis of good patient care and are essential elements for providing a total healthcare service. Medical assistants must know what to watch for and what to expect. It is important to be able to recognize even the slightest change in a patient's condition, since such changes indicate a definite improvement or deterioration. Medical assistants must be able to recognize the desired effects of medication and treatments, as well as any undesirable reactions to them. Both of these factors may influence the physician's decision to continue, modify, or discontinue parts or all of the treatment plan.

Oral and Written Reporting

Equally as important as assessments is the reporting of data and observations to the appropriate team members. Reporting consists of both oral and written communications and, to be effective, must be done accurately, completely, and in a timely manner. Written reporting, commonly called recording, is documented in a patient's medical record.

Maintaining an accurate, descriptive medical record serves a dual purpose: It provides a written report of the information gathered about the patient, and it serves as a means of communication to everyone involved in the patient's care. The medical record also serves as a valuable source of information for developing a variety of care-planning activities. Additionally, the medical record is a legal document and is admissible as evidence in a court of law in claims of negligence and malpractice. Finally, these records serve as an important source of material that can be used for educating and training medical assistants and for conducting research and compiling statistical data.

Basic Guidelines for Written Entries
It is imperative that medical assistants follow some basic guidelines when medical assistants make written entries in the patient's medical or clinical record. All entries must be recorded accurately and truthfully. Omitting an entry is as harmful as making an incorrect recording. Each entry should be concise and brief; therefore, avoid extra words and vague notations. Recordings must be legible and in black ink ball-point pen with water-proof ink, and never red ink or pencil! All boxes, and spaces must be filled in, and no open gaps should be left in a page.

Corrections, additions or deletions must be done as neatly as physically possible to the entry being corrected. All such items should be dated and timed with the date of correction and be signed. Errors should have one line drawn through the incorrect information. The original entry must never be obliterated, and must remain legible even after the correction. Finally, entries in the patient's record must include the time and date, signature of the responsible person (the writer,) and their title or professional credentials.

Documentation & Charting

BASIC "RULE" OF DOCUMENTATION:

"Write it right"
The medical assistant must realize and understand that the best protection from professional liability and malpractice lawsuits is good care and good documentation.

"If it wasn't charted it wasn't done!"

Whenever a medical treatment, procedure, or medication has been provided, it is best, and should be documented immediately in the patient's medical record, including the date, time, type of treatment, or medication administered, amount (exactly as ordered by the physician,) and route. The signature of the person who administered treatment or medication must accompany the documentation.

Medication errors must also be carefully documented in the medical record and signed by the person who made the error. Charting must include the date and time, the nature of the error, signs and symptoms experienced by the patient who was given the incorrect medication, and the patient's response to any treatment given.

In addition an incident report should be filled out with as complete information as possible and should be reviewed by the office manager, so he or she can see if there are any system problems that can be addressed through better procedures or training to make sure similar errors do not happen in the future.

Improving Documentation

Improving documentation skills and discovering enjoyment in charting requires personal effort, study, and practice. Self-esteem and the desire to excel can motivate this personal effort, yielding great personal satisfaction, a sense of accomplishment, and professional respect. Some medical offices keep various trip sheets or report form examples. When documenting orthostatic blood pressure it is acceptable to use stick figures to indicate the patient's position during measurement.

Daily Medical Chart Dos and Don'ts:

1. ALL ENTRIES in medical records must be LEGIBLE, DATED AND SIGNED including their professional title and IDENTIFICATION so that any future reader can identify each entry's author.

2. Do not use abbreviations! Use only abbreviations and symbols approved by your medical office, clinic, or hospital

3. Use only approved chart forms with the patient's name, the date, and the time recorded on each sheet and on, if applicable, both sides of every sheet in the record

4. Use ink; never pencil

5. Don't skip lines or leave spaces between entries

6. Don't use vague, non-descriptive terms

7. Don't get personal. Comments cannot be removed or changed. Refrain from entering into the chart any statement that does not deal directly with the patient's diagnosis, treatment, care or condition

8. Don't use the medical record to comment on other health-care professionals or their actions

9. Don't wait until the end of the day to chart all the events of the day

10. Don't back date, add to, or tamper with notes in the medical record

11. Don't use terms unless you (and everybody else) know what they mean

12. Always legibly identify yourself by signature, or initials

13. Federal law mandates that only the professional who charted the entry into a medical record or document can sign it, testifying that was documented is his/her (own!) work.

14. One person cannot sign or initial another's persons notes.

Release of Medical Information

Three federal statutes combine to establish the criteria for collecting, maintaining, and releasing medical treatment records:

• Freedom of Information Act (FOIA)
• Privacy Act
• Health Insurance Portability and Accountability Act (HIPAA)

Freedom of Information Act
The Freedom of Information Act governs the disclosure of documents compiled and maintained by government agencies.

Privacy Act
The public's concern over the inner workings and functioning of the government was the reason for the creation of the FOIA. However, it became obvious that a balance had to be made between the public's right to know and other significant rights and interests. One of these competing interests was the protection of an individual's personal right to privacy. In response to this need, the Privacy Act of 1974 was enacted. The stated purpose of the Privacy Act is to establish safeguards concerning the right to privacy by regulating the collection, maintenance, use, and dissemination of personal information by federal agencies.

Any organization, employer, or employee of an agency who willfully violates certain provisions of the Privacy Act is subject to criminal prosecution and fines.

Under the Privacy Act's provisions concerning disclosure of information, there are certain circumstances under which it is permissible to release a prior medical record to a hospital floor where a patient is currently confined, releasing a copy to the patient's new doctor or to a lawyer or insurance investigator .

Requests from attorneys or insurance investigators for medical information about patients may only be answered if the patient has given his/her written consent by signing an Authorization for Release of Medical Information. If the patient is a minor or is incompetent, the patient's parents or legal guardian must sign on his/her behalf. The signed consent must be attached to the patient's record.

Also included in the list of circumstances under which a patient’s medical record may be released are disclosures to a person under compelling circumstances affecting health or safety, pursuant to a court order, and to another government agency for civil or criminal law enforcement activities.

Fact Sheet 8: Medical Records Privacy
http://www.privacyrights.org/fs/fs8-med.htm

HIPAA
The Health Insurance Portability and Accountability Act of 1996, more commonly known as the HIPAA rules and privacy regulations, outline how the health care industry and its business partners must protect patient data, streamline industry inefficiencies, reduce paperwork, and make it easier to detect and prosecute fraud and abuse. HIPPAs goal is to close "privacy peepholes" by restoring the consent requirement, strengthening prohibitions on using private medical information for marketing purposes, and narrowing the purposes for which personal medical information can be disclosed to FDA-regulated entities such as drug companies.

The three main areas of HIPAA compliance for health care providers of which the medical assistant should be especially aware of are:

Security
Requires covered entities that maintain or transmit Patient Identifiable Data to develop
formal methods to safeguard the integrity, confidentiality, and availability of electronic data.

Electronic Data Interchange (EDI)
Requires common format and data structure be used when exchanging specific transaction types, code sets and Identifiers electronically.

Patient Privacy
Requires covered entities to have formal policies and plans regarding who has the right to access patient identifiable health information.

Suggested Activities! 

 Links: 

 Medical Assistant Forum: 

 Chapter Assignment:
Seek practice scenarios for PRACTICE CHARTING (both, medical office and phone call situations)

Advance To Next Chapter Patient Care and Needs
NOTE: Continue only after reading this and the previous lessons!